Received: 7 January 2019 | Revised: 26 September 2019 | Accepted: 13 October 2019

DOI: 10.1111/pde.14037

Pediatric
Dermatology

Baby’s first bath: Changes in skin barrier function after bathing

full‐term newborns with water vs liquid baby cleanser

Carolyn Lund RN, MS1 | Joanne Kuller RN, MS1 | David J. Durand MD2

1
The Newborn Intensive Care Unit, UCSF
Benioff Children’s Hospital Oakland,
Oakland, CA, USA
2
Division of Neonatology, UCSF Benioff
Children’s Hospital Oakland, Oakland, CA,
USA
Correspondence
Carolyn Lund, RN, MS, NICU, UCSF Benioff
Children’s Hospital Oakland, 747 52nd St,
Oakland, CA 94609, USA.
Email: Carolyn.lund@ucsf
Funding information
The study was supported by a grant from
Johnson & Johnson Consumer Co Inc and
by the National Center for Advancing
Translational Sciences, National Institutes of
Health, through UCSF‐CTSI Grant Number
UL1 TR000004. Its contents are solely the
responsibility of the authors and do not
necessarily represent the official views of
the NIH
Abstract
Background: The impact of the newborn's first bath, whether given with water alone
or water with skin cleansing products, on skin barrier function is unknown.
Methods: We evaluated skin barrier function, measured by skin surface pH (primary
outcome), transepidermal water loss (TEWL), and hydration of the stratum corneum
(SCH) in 100 newborns before and after their first bath, randomizing this cohort to
bathing with water alone or with water and a liquid baby cleanser. Two consecutive
measurements of each parameter were obtained at two anatomic locations, the volar
forearm, and below the sternum. Randomization was by mode of delivery, with 50
vaginal and 50 cesarean section (C/S) delivered newborns.
Results: Skin pH decreased significantly following the first bath at both anatomic
sites regardless of whether the bath was performed with water or with cleanser, and
there was no significant effect on the change in pH in these two groups. Baseline
TEWL and SCH measurements were significantly lower in the sternum area com-
pared to the volar forearm. TEWL decreased significantly after the first bath except
when the bath was given with water alone on the sternum site. SCH also decreased
significantly after the first bath except in the forearm when the bath was given with
water alone.
Conclusions: We conclude that skin surface pH, TEWL, and SCH all decrease sig-
nificantly following the first bath, an indication of the development of skin barrier
function in the newly born infant. In addition, bathing with water alone or water and
a liquid baby cleanser does not impact the developing skin barrier.

KEYWORDS
barrier function, bath, infant, newborn, skin, transepidermal water loss

1 | I NTRO D U C TI O N biophysical parameters including skin surface pH, transepidermal

The final stages of structural and functional maturation of the skin,
begun in the third trimester of pregnancy, continue over the first
weeks and months of infancy. Important skin functions that rely on
optimal skin barrier maturation include preventing infection, pre-
venting penetration of irritants and allergens, and regulating ther-
mal control. Development of the skin's barrier function, reflected by
water loss (TEWL), and hydration of the stratum corneum (SCH),
undergoes dynamic changes during the neonatal period.1-3 The new-
born's first bath is given during this time of transition.
We aimed to measure the impact of the first bath on skin surface
pH, TEWL, and SCH in full‐term infants. We hypothesized that there
would be no difference in skin pH when the first bath was given
using water alone or water with a soap‐free, liquid cleanser designed

Pediatric Dermatology. 2020;37:115–119. wileyonlinelibrary.com/journal/pde

© 2019 Wiley Periodicals, Inc. | 115

116 | Pediatric
Dermatology
for infant skin, and our secondary hypotheses were that TEWL and
SCH would also show no difference. The effect of delivery type, vag-
inal birth, or cesarean section (C/S) is unknown, and of interest.
2 | M ATE R I A L S A N D M E TH O DS
Research protocol approval was obtained from the Alta Bates Sutter
Medical Center Institutional Review Board (IRB) and the UCSF
Benioff Children's Hospital Oakland's IRB. The study population con-
sisted of 100 healthy full‐term newborn infants, 50 born by vaginal
delivery and 50 by cesarean section (C/S). Exclusion criteria included
respiratory symptoms requiring oxygen, intravenous antibiotics, ma-
ternal chorioamnionitis, congenital anomalies, or admission to the
newborn intensive care unit. Eligible study subjects were recruited
from September 2012 to May 2013. Written consent was obtained
from the parent(s); only English‐speaking parents were approached
due to lack of interpreters. Parents were asked to consent either
when the nurse caring for the baby and mother was planning to give
the baby's first bath or prior to delivery if the birth was by scheduled
C/S. Because it is unknown whether the delivery type impacts skin
function in response to bathing, an a priori decision was made to
include an equal number of C/S and vaginal births. The standard of
care at the time of this study in this unit was for all infants to receive
a bath during the first hours of life.
Subjects were randomized according to a balanced block design
and stratified according to delivery mode. The randomization se-
quence was generated from a random number table, and random-
ization assignments were placed in sequentially numbered sealed
envelopes. The research nurse who would be obtaining the axillary
temperature and skin measurements was blinded to the type of
bath, water alone, or water and mild baby cleanser, as the envelope
was not opened until the research nurse who was performing the
skin measurements left the room.
These subjects were simultaneously enrolled in a study of the ef-
fects of bath type on skin microbiome. Those results will be reported
in a separate manuscript.
2.1 | Treatment protocol
The subject's nurse contacted the study personnel when the axil-
lary temperature measured >97 degrees F, and she was planning to
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LUND et al.
using the VapoMeter SWL‐2™ (Delfin Technologies Ltd). SCH was
measured using the SkiCon 200EX™ (IBS Company).
The infant was stabilized under a radiant warmer, with the two
study sites, volar forearm and beneath the sternum, exposed for
10 minutes. A research nurse measured axillary temperature, pH,
TEWL, and SCH; two sequential measurements for pH, TEWL, and
SCH were performed at the two anatomic sites. After this, she left
the room, and the second research nurse opened the sealed enve-
lope indicating whether the bath would be given with water alone
or water and five milliliters of liquid baby cleanser, and proceeded
with the bath. The subject was bathed using immersion technique
with gloved hands (not a wash cloth); the bath lasted no longer than
5 minutes. Vernix caseosa, if present, was left undisturbed. The sub-
ject was dried using a warm blanket and returned under the radiant
warmer for 10 minutes. Measurements were repeated by the re-
search nurse blinded to the randomized designation.
2.2 | Statistical methods
Analysis of demographic and descriptive characteristics of the study
population including sex, gestational age, postnatal age, birthweight,
and type of delivery used standard parametric and non‐parametric
statistics, such as t tests and chi‐square tests, to assess for group
differences. The primary and secondary hypotheses were tested
using linear regression models to assess the change from prebath
measures. We modeled the change in pH, SCH, and TEWL from
prebath, as a function of treatment group (water alone vs liquid baby
cleanser), site (forearm vs sternum), and the interaction of treatment
group and site. In addition to adjusting for any effects due to the
TA B L E 1 Demographics and baseline (prebath) measurement of
skin barrier function (mean + SD)
Cleanser Water
N 49 51
Male/Female 25/24 25/26
Gestation (wk) 39.3 ± 1.0 39.4 ± 1.0
Birthweight (g) 3490 ± 472 3470 ± 385
Age first measurement 1:09 ± 1:43 0:59 ± 0:37
(h:min)
Delivery (vaginal/cesarean) 24/25 26/25

bathe the infant. All subjects were bathed according to the study Baseline values
protocol: immersion bath with water temperature 101 degrees F, pH—forearm 7.17 ± 0.45 7.04 ± 0.45
depth 5 inches(12.7 cm), which has been shown to be safe even with pH—sternum 7.11 ± 0.61 6.97 ± 0.53
4,5
the umbilical cord in place and swaddle technique to reduce infant SCH—forearm 184.5 ± 284.0 272.1 ± 338.3
distress.6 For subjects randomized to bathing with water and liquid SCH—sternum 49.3 ± 32.7 53.2 ± 56.6
baby cleanser, Johnson & Johnson's Head‐to‐Toe™ was used, as this TEWL—forearm (g H2O/ 117.4 ± 114.7 109.4 ± 98.2
product was used at the time at this facility. It is a soap‐free liquid m2/h)
cleanser designed for newborn and infant skin, is sodium lauryl sul- TEWL—sternum (g H2O/ 46.0 ± 47.4 38.1 ± 37.9
fate‐free, and pH‐adjusted. m2/h)
Skin pH was measured using the Skincheck HI 98109™ (HANNA Note: There were no significant differences between the cleanser and
Instruments). TEWL was measured by closed chamber evaporimetry the water in infants for any of these values at baseline.
 15251470, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pde.14037 by Nat Prov Indonesia, Wiley Online Library on [02/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
LUND et al. Pediatric | 117
Dermatology
prebath values, these models adjusted for sex, gestational age, and Skin pH
Forearm (FA) and Sternum (St)
type of delivery. 10
The study was powered to show a pre‐ vs postbath difference
in skin pH of at least 0.4 pH units, as cited in other published re- 9
* P < .01 Pre- vs Postbath
search.1,2 We recruited 100 subjects, stratified by vaginal vs C/S de- ** P < .001 Pre- vs Postbath
livery (50 each), to show a difference in skin pH, assuming an alpha 8
error (P value) of .05 and a beta error of 0.2 (power of 0.8). The sta- ** ** ** *
tistical analysis was performed using SAS version 9.4 software.

pH
7

6
3 | R E S U LT S
5
One hundred infants were randomized to receive their first bath
with water alone or water and liquid cleanser. Infant demographics 4
and baseline pH, TEWL, and SCH for sternum and volar forearm are FA Cleanser FA Water St Cleanser St Water
shown in Table 1. The vaginal birth cohort was bathed 91 ± 53 min- Prebath Postbath
utes after delivery, while the C/S cohort was bathed at 31 ± 20 min-
utes. The subjects’ axillary temperatures ranged from 98.1 to 98.5 F I G U R E 1 Skin surface pH by site and type of bath. P values
represent the difference between pre‐ and postbath measurements
degrees F prebath and 98.1 to 98.3 degrees F postbath.

forearm. Following the bath with either water or cleanser, the SCH
3.1 | Skin surface pH decreased significantly when measured at the sternum. However,
the SCH measured at the forearm decreased significantly follow-
Skin surface pH, measured at both sternum and forearm, de-
creased significantly following the bath (Figure 1). There were no
differences between anatomic sites. Bathing with water alone or Transepidermal Water Loss (TEWL)
Forearm (FA) and Sternum (St)
with water and cleanser had the same effect on the change in skin 250
pH. Gestational age, sex, and type of delivery did not affect the
change in skin pH. **
200 * P < .01 Pre- vs Postbath
** P < .001 Pre- vs Postbath
**
3.2 | Transepidermal water loss
TEWL (g/m2/h)

150

Differences were seen between TEWL measured at the forearm com-

pared to the sternum, both before and after the first bath (Figure 2). 100
A borderline interaction of group and anatomic site was found in the *
change in TEWL before the bath (P = .096) implying the treatment
50
group differences may depend on which site is considered, so a model
was developed to examine each site separately. TEWL decreased sig-
nificantly following the bath on the forearm for both water alone and 0
FA Cleanser FA Water St Cleanser St Water
water with cleanser, and for the sternum following bathing with the
cleanser, but not for this site when bathed with water alone (Figure 2). Prebath Postbath

The change in TEWL was significantly associated with gestational

age, with the older gestational‐age infants showing a greater change
in TEWL between pre‐ and postbath measurements (P = .10). In ad-
dition, a significant change in TEWL for the forearm site was found
based on the type of delivery (cesarean delivery mean (g/m2/h) ±
SD = −57.5 ± 82, vaginal delivery −19.5 ± 58.3) (P = .017).
F I G U R E 2 Transepidermal water loss (TEWL) by site and type of
bath. P values represent the difference between pre‐ and postbath
measurements
ing the bath with cleanser, but not following the bath with water
alone (Figure 3).

3.3 | Stratum corneum hydration

Similar to TEWL, there was a significant site difference in the 4 | D I S CU S S I O N
change of SCH at the two anatomic sites (P = .023), and we exam-
ined a model for each site separately. Prior to the bath, SCH was On the first day of life, skin surface pH is >6.0 falling to <5.0 during
lower when measured at the sternum than when measured at the the first weeks of life. 3,7 Once the acid mantle of the skin surface

118 | Pediatric
Dermatology
Stratum Corneum Hydration
Forearm (FA) and Sternum (St)
700
Stratum Corneum Hydration (units)
600
* P < .01 Pre- vs Postbath
** P < .001 Pre- vs Postbath
500
* are inconclusive. 20,21
400
300
200
** **
100
0 liquid baby cleanser.1
FA Cleanser FA Water St Cleanser St Water
Prebath Postbath
F I G U R E 3 Stratum corneum hydration (SCH) by site and type of
bath. P values represent the difference between pre‐ and postbath
measurements
is established, bathing can transiently alter the skin pH, even with
water alone, in older infants and adults. 8,9 Thus, bathing has the
potential to alter the development of the acid mantle of newborn
skin.
Our study found giving the very first bath with water alone
or water and a liquid baby cleanser did not result in an increase in
skin pH. In fact, the skin surface pH decreased significantly in both
groups. It is important to note that the changes seen in our study
represent only a single time following a single bath. However, these
findings are similar to studies comparing bathing with mild baby
cleansers to water alone during the first month of life.10-12
Transepidermal water loss and SCH also decreased significantly
after the first bath regardless of whether the bath was water alone
or water and cleanser and were significantly higher on the forearm
compared to the sternum, a finding reported previously.3 This may
be because in utero the arms are predominantly in flexion, which al-
ters the skin barrier similar to that seen in other intertriginous areas
such as neck folds, axilla, and groin.
We report TEWL measurements that are significantly higher
than other studies.3,13 This may be due to measuring techniques,
as we used closed chamber evaporimetry while other studies used
open chamber devices. In addition, our measurements are among
the earliest reported, in some cases as early as 30 minutes after de-
livery. Rutter and Hull14 report high TEWL levels in the first hours
after birth in newborns 34‐41 weeks gestation, which subsequently
fell after 4 hours.
There continues to be controversy about when and how to give
the newborn their first bath or even whether to bathe newborns
at all.15,16 The primary concern is to protect against hypothermia
as well as promoting skin‐to‐skin holding, and current guidelines
are recommending waiting 6‐24 hours17,18 unless the mother is
HIV positive; in this case, the newborn should be bathed as early
15251470, 2020, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pde.14037 by Nat Prov Indonesia, Wiley Online Library on [02/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
LUND et al.
as possible to prevent transmission of infection.19 In our study, the
bath was given much earlier than some current recommendations,
yet our subjects did not experience hypothermia despite being
bathed soon after delivery. The current trend is to delay bathing
beyond 12 hours of life in an effort to increase exclusive breast-
feeding at hospital discharge, although the results of several studies
Another consideration regarding the first bath is to leave vernix
caseosa undisturbed. Vernix is the protective fetal film that accumu-
lates during the third trimester of pregnancy, with the thickest accu-
mulation at 36‐38 weeks gestation. However, if vernix is not actively
removed, the beneficial effects in terms of skin surface acidification
and hydration are seen, even after bathing with warm water and a
In conclusion, in our study the newborn's first bath resulted in
a significant decrease in skin pH, TEWL, and SCH. These changes
were not influenced by whether the bath was given using water
alone or water and liquid baby cleanser. No anatomic site differences
were seen for skin pH, but were seen for both TEWL and SCH, with
TEWL and SCH measurements higher in the forearm.
AC K N OW L E D G M E N T
The authors thank the First Bath Study Nurses and the staff in labor
and delivery at Alta Bates Summit Medical Center, as well as Ginny
Gildengorin, PhD, for her statistical support.
ORCID
Carolyn Lund https://orcid.org/0000-0001-9843-7769
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How to cite this article: Lund C, Kuller J, Durand DJ. Baby’s
first bath: Changes in skin barrier function after bathing full‐
term newborns with water vs liquid baby cleanser. Pediatr
Dermatol. 2020;37:115–119. https​://doi.org/10.1111/
pde.14037​